Case Study: Checking vaccination status at entry to, or during, school THAILAND Law or policy What is the law or Vaccination history check at school entry is a “recommended” policy, i.e. policy? it is not a mandatory policy. Year first established? 2013 Who issued the law or The policy was supported by the Ministry of Public Health (MoPH) and the policy? Ministry of Education (MoE) as part of Component 5 of the Health Promoting Schools Initiative (HPS). Scope? All schools under the MoE, Office of Basic Education Commission. Implementation Funding Although all hospitals and health centres provide immunization services free of charge, no additional funding is provided to schools to support school-based immunization activities nor for the checking of vaccination status. Resources are generated by a network of leaders, parents and students when needed. Who checks? The teachers of the children entering Grade 1 and Grade 7 collect the immunization history record from parents, and make a photocopy. The responsible health officer then checks the immunization histories for completeness. Information used to The immunization history of the child is contained in the Mother and Child check vaccination status Health Handbook or other vaccination card. What is done if children If a child is identified as un- or incompletely vaccinated, they are either are missing doses? referred to the local hospital or health centre to receive catch-up vaccines, or in some schools, health care staff may come to the school to deliver catch-up vaccines. An accelerated vaccination schedule is included in the national immunization programme schedule to provide guidance on how to vaccinate older children up to 7 years of age who have missed vaccines. Guidance and In 2013, the recommended policy was communicated to all schools by enforcement letter from the MoE which was accompanied by implementation guidelines. The vaccination screening policy is a recommendation only. It is not mandatory for schools to comply. There has been no active promotion of follow up on implementation by either the Ministry of Public Health or the Ministry of Education. Monitoring and A monitoring and evaluation plan was considered in the design of the Evaluation policy, but no system has been established to measure progress or effectiveness of this strategy. CASE STUDY: Checking vaccination status at entry to, or during, school - THAILAND Page 1 of 11 © UNICEF/UNI105758/Mohan BACKGROUND: Current estimates show a 2019 population in Thailand of 69.31 million, making it the 21st most populous country on earth. It is estimated that there are further 2.2 million unregistered illegal and legal migrants in Thailand increasing those numbers even further. Based on 2011 population figures, Thailand has a population density of 132.1 people per square kilometer (1). The National Immunization Programme (NIP) was introduced in Thailand in 1977, and since 2005 the NIP has consistently achieved immunization coverage of around 96–99 % among Thai children. The antigens contained in the Thai national immunization schedule are shown in Table 1 below. Thailand has a comprehensive multi-year plan for immunization for the period 2017-2021, and an annual workplan for immunization activities each year. Thailand is strongly committed to eradicate polio by 2018 and eliminate measles by 2020; however, a few challenges remain in the south of the country and among migrant communities. Thailand has never benefitted from support from Gavi, the Vaccine Alliance, and an actual GNI per capita of $5,950 means that is still the case. Universal health care (UHC) for Thai citizens, introduced in 2002, extended the scope of coverage to 18 million people who were uninsured and to a further 29 million who were previously covered by less comprehensive schemes. A Migrant Health Insurance Scheme has also been added. Since UHC introduction, public expenditure on health steadily increased from 56% in 2000 to 86% in 2011, while out-of-pocket expenditures decreased from 27.2% to 12.4% of total health spending. However, significant challenges remain (2). CASE STUDY: Checking vaccination status at entry to, or during, school - THAILAND Page 2 of 11 The Education system The education system in Thailand consists of the following (see chart below): ▪ Pre-primary from ages 3-6 ▪ Primary (Grades 1-6) from ages 6-12 ▪ Secondary (Grades 7-12) from ages 12-18 The law entitles all children within Thailand to enroll in school, regardless of their background or nationality. According to UNESCO’s 2017/18 Global Education Monitoring (GEM) Report, 99% of children complete primary education in Thailand (3). The Health and Immunization System The administrative system in Thailand is made up of 76 provinces plus the Bangkok Metropolitan Area, which has its own administration system. The health system in Thailand consists of 3 levels: For the 76 provinces: There are 9,770 health promoting hospitals or health centres delivering health services at primary care level. They provide holistic health services including health promotion and prevention, primary treatment and rehabilitation at sub-district level. There are a further 771 community hospitals providing secondary health service at district level. For the Bangkok Metropolitan Area: There are 68 public health centers responsible for primary care similar to the health promoting hospitals in the provinces. There are a further 39 public hospitals and 92 private hospitals in the metropolitan area of Bangkok. CASE STUDY: Checking vaccination status at entry to, or during, school - THAILAND Page 3 of 11 The immunization service is integrated in the primary care units of all public health facilities in Thailand. Private hospitals and clinics also play an important role in providing vaccination service in Thailand. Unofficial data from the vaccination coverage survey conducted in Thailand in 2018 revealed that the private sector was responsible for 30% of all immunizations provided to children in Bangkok. However, the figure for private sector involvement in other provinces is lower at around 10-15%. The National Immunization Programme (NIP) was introduced in Thailand in 1977, and since 2005 the NIP has consistently achieved immunization coverage of around 96–99 % among Thai children. Schools provide routine immunization for HPV (Human Papilloma Virus) for girls in Grade 5 (11 years of age), and Td (tetanus and diphtheria) for both boys and girls in Grade 6 (12 years of age). However, vaccination rates among children along the Thailand-Myanmar border are notably lower (4). This is a region with many highly mobile and migratory people for whom receiving age-appropriate vaccines can be extremely difficult. The Ministry of Public Health is responsible for the pre-school health programme and the school health programme in close collaboration with the Ministry of Interior (pre- school) and the Ministry of Education (school). In Thailand, the WHO-recommended Health Promoting Schools Initiative (HPS) has been supported by the Ministry of Public Health to support health promotion in schools. According to the MoPH in 2017, over 88% of schools in Thailand were participating in the HPS Initiative (5). HPS consists of 10 elements for assessment and implementation: 1) school policy, 2) management in the school, 3) collaboration of school and community, 4) creating environments supportive of health, 5) school health services, 6) health education in school, 7) nutrition and safety of food at school, 8) exercise through sport and recreation, 9) provision of counseling and social support, and 10) health promotion for school staff. The fifth component is of direct relevance to this case study. Recent evaluations of the HPS Initiative (6, 7) identified the following two main factors for its success: (1) The role and engagement of school directors; and (2) the degree of collaboration between all parties, i.e. parents, students and teachers. The main obstacles identified were the lack of compliance by parents – which was overcome by education from subject matter experts - lack of a clear implementation policy, lack of staff time, poor cooperation between the main parties and shortage of resources. LAW OR POLICY Establishment of law or policy for checking of vaccination upon school entry In 2013, the Government of Thailand introduced a recommended policy for a vaccination history check of children at entry to Grade 1 (primary school) and Grade 7 (secondary school). The intent was as part of pillar 5 of the HPS Initiative, to increase the immunity of individuals, to prevent outbreaks of vaccine- preventable diseases in schools, and to improve school health programme management. This policy was communicated nationwide to all schools under the Ministry of Education (MoE) as part of Component 5 of the School Health Promotion Programme (SHPP) by a letter from the Ministry of Education, accompanied by guidelines to implement the vaccination history check. Both the letter and the guidelines were developed in collaboration with the Department of Disease Control (DDC), Division of Vaccine Preventable Diseases (DVPD) in the Ministry of Public Health (MoPH). CASE STUDY: Checking vaccination status at entry to, or during, school - THAILAND Page 4 of 11 The letter details that the vaccination history check performed by schools at entry to Grade 1 (children 7 years of age) should include all vaccines recommended on the Thailand National Immunization Schedule (shown in Table 1 above) from birth to four years of age. For those children identified as un- or incompletely vaccinated, the Thailand National Immunization Schedule includes an accelerated schedule to help children receive catch-up vaccination that includes: BCG, OPV, MMR, HepB, live attenuated JE, IPV (for children aged 1-6 years), DTP (for children aged 1-6 years), and Td (for children aged 7 and older). The un- or incompletely vaccinated child is either referred to the local hospital or health centre to receive the catch-up vaccines, or, in some schools, health care staff may come to the school to deliver the catch-up vaccines.